Healthcare Provider Details

I. General information

NPI: 1487063574
Provider Name (Legal Business Name): NICK PAUL JUNG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAC LN
PIERRE SD
57501-3391
US

IV. Provider business mailing address

1118 LAKEWOOD DR
PIERRE SD
57501-5231
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-5901
  • Fax:
Mailing address:
  • Phone: 605-280-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberSD-CRN CR000860
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: